Day 40 through Day 5: Its all a blur

Blur (blûr) v.

1. To make indistinct and hazy in outline or appearance; obscure.
2. To smear or stain; smudge.
3. To lessen the perception of

As those who follow this blog know, we have been counting down from the 90 day mark toward our grand opening. The actual countdown has been expanded by the time-space continuum in that as you approach the speed of light time actually slows down.

Crossover Health Showroom feature wall and self check in area.
Crossover is all about a simple, affordable, and efficient health care experience.

However, the last 35 days have zoomed by without me providing the regular updates so here you go:

• Finished buildout
• Finished finish work
• Completed cement work in Showroom
• Build out of furniture (we did it all at Ikea!)
• Worked out workflow issues with new software, new site, and new team
• Build out XR room
• Completed marketing campaign
• Finished new website
• Repainted extra space
• Cleaned up, hauled out, polished up, rubbed off, and general spitshine
• Invited friends and family to join us in Opening!

The good news is alot of it was captured on video or time lapse and I will be making some pointed comments in future posts regarding several aspects of our buildout and preparations for launch. Needless to say, it was a fabulous experience and we worked with an amazing high end retail builder – Display It – to create a space that is equal to the opportunity that we are pursuing. So take a long look . . . its all a blur to me.

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Day 54: Learning from AMEX why membership has its privileges

* This is a guest post by Stephen Gaines, our Director of Membership Experience at Crossover Health. He will be talking about his role, what he does, and how everything we do is focused around how the Crossover brand can consistent deliver an exceptional experience in future posts

In 1958, American Express redefined the “Charge Card,” by introducing the American Express Card.  The card was a far cry from today’s modern Credit Cards.  It was made of paper and had the card members name typed on it.  The membership fee was $6 a year and required the member to pay the balance in-full each month.  What made membership so popular was the worldwide network of offices, travel agents and associated banks that were available to card members.  Before it’s release date of October 1, 1958, American Express had issued more than 250,000 cards!

As American Express Card evolved, it earned a reputation for the having the highest customer service standard.  AMEX employees were regularly encouraged to go above and beyond the call of duty.  One representative hand delivered a card in the middle of the night to a stranded cardholder at Boston’s Logan airport.  Another instance involved a representative in New Delhi who arranged for another representative’s brother (a military helicopter pilot stationed close to the caller) to deliver cash to an AMEX Gold cardholder who was stranded in a remote village in the Himalayas.

History is about to repeat itself. Starting this fall, Crossover Health will redefine healthcare as we know it by introducing a new standard in healthcare.  Like American Express, Crossover Health will feature a membership based experience that rivals fine hotels and retailers.  Imagine having care that allows your physician to practice medicine independent of insurance companies while offing unprecedented access.  And best of all – it’s affordable!

When did going to the Doctor become so negative?

Today, visiting a physician’s office is rarely a pleasant experience.   We’ve all grown accustomed to reading back issues of People Magazine while we wait for our notoriously late physician.  Once inside, we’re lucky if we have 10 minutes and a full conversation.

Back in the day, physicians were held in high esteem.  Changing doctors was unheard of because people stayed with their doctor long-term.  Doctor’s offices were a place of community not disharmony.  The result has left most patients feeling blasé about there healthcare experience.   Bad customer service, insurance coverage complications, and the inability to cross compare service pricing have resulted in high patient defections.

The truth of the matter is, we’ve become so accustomed this type of medical treatment, that we don’t expect anything different.

Membership Privileges

This fall, Crossover Health will introduce a new standard in membership focused healthcare.  Crossover Health will combine world class customer service, straight-forward pricing, and a suite of healthcare tools, services and resources that will be exclusive benefits for its members.

Physician Interaction

Physician interaction has traditionally been limited to office visits.  However, Crossover Health intends to change the way we interact with our physician.  Imagine attending weekly workshops, benefiting from a tight partnership between a third-party healthcare provider or taking part in a special field trip to a local organic supermarket – all lead by your physician!

Proactive Goal Setting

Most physicians today only see patients when there is a urgent need.  Rarely if ever are patients seen outside of an illness or injury.  Crossover Health intends to change this experience by seeing patients before something happens.  Members will have the ability to create Annual Healthcare Blueprints in partnership with their physician and a trusted third-party providers such as personal trainers and nutritionists.  These blueprints will create a framework and set goals fort he coming year.

Better Communication through Technology

Although, physicians tools have changed a lot over the years, patient communication is still limited.  Patients are demanding communication standards that are used in regular forms of business like: email, instant messaging and video chat.  Crossover Health will employ all three methods for it’s members.

As American Express did in the 1950’s, Crossover Health will define a higher standard in healthcare – one that will be affordable, accessible and patient focused.  Keep an eye out for Crossover’s new location opening this fall in Aliso Viejo, California.

Day 65: Proof is in the Passion – Crossover Explained

Passion

Tonight I attended an awesome charity event called Savannah’s Organic Ranch. Savannah was a beautiful girl stricken with cancer whose last wish was to pass along her love of organic farming. The spark that was her life and encapsulated in her last wish has fueled a community wide passion for spreading representative organic “ranches” at local schools and in our community. I was impressed with the passion of this young girl, and how it has inspired equally vibrant passion for those who wish to keep her memory alive for a great cause.

I believe passion is an integral part of life and anyone’s life’s work. At several forks in my professional journey, I have chosen to pursue my passion instead of settling for a more secure road. It has been a defining characteristic in my life – one in which I have occasionally questioned during challenging times but have always known was my destiny. I find myself once again passionate about what I am attempting to do, and the familiar sense of being energized by both the general impossibility of the task at hand coupled with the equally strong sense of inevitability with which all entrepreneurs are endowed.

Instead of writing it out, I thought I would just capture what I am doing on video:

Saves me time, provides some strong visualization of our business, and hopefully conveys the passion I feel about what we are doing.  We will be using this blog and our other channels to tell our evolving story, as well as the entrepreneurial extremes we experience as we drive toward launch. Hope to make this a dialogue as we roll forward.

* For those of you wondering whats up with our broken down building, this video was shot by Benny Ek Media within our new space following its demolition. We look forward to introducing our new design, look and feel.

Customer Disservice: Health Care #FAILs again and again

Disservice (dĭs-sûr’vĭs)

1. A harmful action; an injury
2. An act that is not just

Our health care system is completely devoid of customer service. It is pathetic.

I took my son to have a simple tympanostomy (ear tubes) procedure this morning. I show up, sign in and take my seat amidsts the throngs of people in the surgical center waiting room. I brought my laptop and some reading materials to bunker down for the long wait ahead.

20 minutes later I get called up front to sign some additional paperwork. Instead of being greeted, 15 documents each complete with a full page of legalese is shoved my way regarding various aspects of responsibility, payment, agreement, arbitration, and host of other information. The grumpy lady has clearly done this a thousand times and she has absolutely no tolerance for any of my questions. She paries my first few skillfully, but I don’t let her blunt my questions regarding the finances.

She shows me that the facility is charging me $5,600 but that fee has been reduced by the insurance to $1,799. This is an all in fee for the facility only (includes staff, equipment, monitoring, etc) and does not include fees charged by the physician and the anesthesiologist. I ask what those charges will be (I already knew ahead of time), but she says she is not responsible for their charges and that I would have to speak with those providers about that. I start asking her why they don’t bundle everything into one price so I can compare across various combinations of facilities and providers. She has no idea what I am talking about and ends the conversation by giving me their phone numbers. Take your seat Mister, how dare you ask a question about pricing comes across clearly as she stares me down to my seat.

I immediately pick up the phone and talk to the physician office. After about 10 minutes, I finally get the billing person who is able to provide me the CPT code (69436) and Zip Code (92691) as well as what they charge for procedure ($345). I tell here I am not interested in her price because it is irrelevant and that Blue Cross has already dictated the price that you are going to get. A little defensive, she then relays to me the the administratively set Blue Cross reimbursement that has been dictated to this particular physician ($208.08).  I then ask her about bundling of services and created an Ear Tube product that would include all the components so that I can compare across facilities and providers. She has no idea what I am talking about. I give her the hamburger example (I don’t get separate receipts for tomoatoes, buns, and burger – I get a single price for the thing I want – the complete hamburger). I refer her to Carol.com as an example and she thinks this sounds like a good idea.  When I ask why they don’t do it now that she understands, she says that she doesn’t think the physicians would ever agree to work in that way. She tells me she will pass this along to the physicians, and with a laugh that indicates that will never happen, we end the call.

Next, I call the anesthesiologist group. First the lady attempts to tell me she can’t give the pricing because it is a HIPAA violation. I quickly disabuse her of her ignorance and get her manager on the phone. Anesthesia is unique in all of medicine because anesthesiologist charge for their time in increments called units (typically 15 minutes). So they get a “set up” fee and a “time-based” fee for their services, both in terms of units. So I ask them what their per unit charge is and the manager tells me that it is proprietary information. I call him out on it and say that pricing information is not proprietary, perhaps his costs structure is, but he has a duty to tell me the cost of the service I am about to engage him in. I am pretty frothy at this point and really lay into this guy. He still refuses to tell me his proprietary, negotiated per unit rate with Blue Cross but relents on giving me the overall price. He then passes me along to someone else who looks up in their database and tells me the cost will be either $300 or $360 for the procedure for either a 15 minute or 30 minute anesthesia time. So, knowing they go in 15 minute unit increments, I can tell that there is either 5 or 6 units involved, and therefore a $60 / unit price. So, full pricing is 4 units “setup” and either 1 or 2 units for their time. So much for your proprietary formula and negotiated pricing. $60 bucks every 15 minutes or $240/hour for anesthesiologist time. Thats mid-tier lawyer rates for South Orange County but interesting in how at least this type of physician’s time might be valued by insurance companies.

So finally, after about 45 minutes of phone time, by someone who knows the ins and outs, all the secret handshakes and covert codes, and most aspects of healthcare financing, I am able to arrive at an all in price for a very simple surgical procedures:

Tympanostomy
CPT Code: 69436
Zip Code: 92691
Facility Fee: $1,699.00
Surgeon Fee:  $208.08
Anesethsiologist Fee: $360.00
TOTAL:  $2,267.08

This is great to know the price information for my selected combination of facility and physicians. However, I have no information on outcomes achieved, safety rates, customer satisfaction, or other metrics to determine if I would not be better off with a different combination of facilities and physicians. What do you think the response was when I attempted to ask about health outcomes for my physician?

Pin drop, anyone?

This is not just another rant, but meant to highlight that the very basic, fundamental courtesies expected during a consumer transaction are all but non-existent in health care. Simple things like getting pricing information, like getting helpful customer service, like understanding what you are buying, and the quality features that attract you to purchase something in the first place. Health care should be one area where customer service is impeccable. I believe you begin to see “brands” emerge that get this, invest in it, and deliver it consistently over time. Looking forward to the ongoing retailization of health care – it truly needs it.

Sermo makes the connection: Health Reform leads to Cash-based Practices

Connection (kə-nĕk‘shən) n.

1. The act of connecting.
2. The state of being connected
3. An association or relationship

Sermo finally makes the connection between all the health insurance reform conversations and the inevitable consequence of pushing a large percentage of providers toward a cash based practice. I have highlighted the rise of direct practice multiple times, and believe enough in the model that I am currently creating a direct practice network for Southern California. There are multiple emerging tools that will make this much easier and I believe the inevitable financial reimbursement fallout will result in a dramatic rise in the number of physicians moving to this model.

The comments below are only available once you log into Sermo:

The past two weeks have seen polls come out that would appear to portray physicians with diametrically opposite positions in the current healthcare debate. A September 14^th poll of 5,157 physicians in New England Journal of Med… indicates that:

• 63% of physicians support a combined public/private approach to coverage (i.e. the healthcare reform approach currently proposed)

A poll two days later by IBD/TIPP of 1,376, also randomly selected physicians, indicated that [LINK]:

• 65% say they oppose the proposed healthcare plan
• 45% of the respondents stated that they would consider leaving medicine if the reforms were in fact enacted

In parallel, there has been a dramatic acceleration in the number of discussions around cash-on… While fee-for-service or “cash only” practices have long been a popular topic on Sermo, there appears to be increasing interest in this as the healthcare debate has progressed.  Given the growing impact of this trend, the media is asking the Sermo physician community to help asses this trend and the possible impact on the physician-patient relationship.

Sincerely,

Daniel Palestrant, MD
CEO & Founder, Sermo

P.S. Get your colleagues involved. And help us make a big statement to the media. Cut and paste this link into your outgoing email: https://md.sermo.com/medical/ticket/details?id=41104

Whats the new spelling for the AMA? S-E-R-M-O

Spelling (spĕl’ĭng) n.

1. The forming of words with letters in an accepted order; orthography.
2. The art or study of orthography or the way in which a word is spelled.

Whoa . . . just ahead of a 21% cut in physician salaries we have an epic battle shaping up within the physician community. The AMA, long the Godfather and voice of physicians around the country, apparently is feeling the heat from a younger, more svelt upstart from across (cyber)town. I have just received back to back emails from Sermo CEO Daniel Palestrant essentially declaring his succession from the physician union. This comes at a critical time when further fracturing of physician leadership and political strength put in jeopardy the opportunity for the physicians to have a unified voice (or is it because the stakes are so high that this group is compelled to speak up?):

The leading missive from 7/1/09 (might require log in):

Dear Dr. Shreeve,

As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.

The AMA has drawn its power from the support of the physician community. The waning membership reflects our objection as the AMA has failed us consistently for over 50 years. Make no mistake, the debate within the AMA about how to stop their membership decline is not new.  What is new is the lengths to which the AMA appears willing to go to deceive the public on this topic.  The AMA routinely claims that their membership is 250,000 practicing physicians.  At best, this is 25-40% of practicing US physicians and even that claim is based on some stretching of the truth.  The 250,000 total includes a number of non-practicing constituencies, including medical students, residents, and subscribers of the AMA’s journals.  Paying membership is generally accepted to be far lower.  How much lower?  Actual numbers are remarkably difficult to come by.

At this critical moment in history, we cannot watch the AMA fail physicians so completely yet again.  Nor can we stand by and let false perceptions about who speaks for physicians persist. At the very least, all parties should understand the intrinsic conflicts of interest that are in play, and the AMA should be held accountable to these truths.  Better yet, physicians should call for sweeping changes within the AMA.   In the best-case scenario, the AMA will shed its relationships with insurers and abandon tactics that take advantage of physicans to generate millions of dollars in revenue.  It is an inherent conflict of interest to claim advocacy for physicians while profiting from a reimbursement system that makes it increasingly difficult for physicians to practice medicine.

The flight from the AMA signals that physicians don’t believe the AMA is willing to make these changes. The longer that the public and our lawmakers cling to the perception that the AMA represents the voice of US physicians (and the AMA succeeds in perpetuating this), the more imperiled the medical profession will be and with it the broader US healthcare system.  It’s time to turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession.

There can be no healthcare reforms that have any chance of succeeding without buy-in from physicians.  As a country, we cannot risk another failed reform effort.  As physicians, we cannot risk letting the AMA represent our interests.  This is our time to educate the public about which voices truly represent us and our commitment to our patients.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.

The follow on upper cut (From 7/2/9):

Dear Dr. Shreeve,

Yesterday I posted on Sermo about the need for a new voice to represent physicians. The Sermo community’s response was clear. 2,400+ physicians voting in less than 24 hours. 90% say that the AMA does not represent them. That is a bold statement and the general public will take note.

The need for physicians in this country to have a strong voice has never been greater. And Sermo, a community of well over 100,000 US Physicians, needs to make its voice heard. Yesterday’s posting was the beginning of a regular series that will make your voice heard on issues critical to our profession. Results from these postings will be publicized to the media.

Believe it or not, we are already making dramatic progress. I have been contacted by major media outlets who are interested in what physicians on Sermo have to say. Beginning next week our voice will be heard.

Add your voice to the first topic:

The Biggest Risk to US Physicians Today: The AMA

Sincerely,

Daniel Palestrant, MD
CEO & Founder
Sermo Inc.

I have commented about Sermo before (here and here). I think it can be a useful tool – the virtual lounge if you will – which I totally get. Some of the hallway conversations were useful, but I had other settings in which to engage to my clinical and personal satisfaction. And just like the real thing, I never felt comfortable hanging out in the posh lounge with slightly better food when all my patients, colleagues, and fellow health care workers were sent somewhere else. It is the same discomfort I feel on the rare occasions I have flown first class and sat uncomfortably watching all the “regular” people pass pass on the way to the back of the plane.

Obviously a Sermo style virtual lounge has alot of potential and possibilities. While some of my previous comments can be taken as somewhat down on the platform, I am generally very much in favor and supportive of what Sermo is doing. In fact, I believe the collective intelligence within the network is a wonderful place to harness the cognitive surplus of physicians. Moreover, online communities of experts who can share real medical knowledge in real time, discuss and comment in warp speed peer review, and allow a business commodity to be created from voyeurism certainly has earned my respect.

The breakthrough is not in the message nor even the messenger, it is the manner in which I am getting this message that is most impressive. 100,000 physicians strong (and growing), online and interactive, and now muscling up for the biggest fight of their life. Perhaps most useful of all, is the ability to aggregate the physician voice into a common unified message. My articles above highlight the role of aggregators, and this specific type of network effect grows in influence and power to the point of being a  political force to reckon with. Perhaps the 100,000 member barrier represents the political tipping point to take on the slothful big brother?

Should be interesting to follow – looking forward to seeing if the new kingpin has the staying power to dislodge the king. Looks like he has certainly swiped the scepter.

The Vitality Index: The Return of the Health Care FICO Score

Vitality (vī-tăl’ĭ-tē)

1. The capacity to live, grow, or develop.
2. Physical or intellectual vigor; energy.
3. The characteristic, principle, or force that distinguishes living things from nonliving things.

I am finding it hard to use financial analogies these days to explain health care concepts given recent events. It’s analogous to the feeling you get when you accidentally use the word “maverick”. But despite the meltdown, I still find the Health / Wealth construct to be very powerful way of effectively communicating emerging health care reform ideas.

One of those worthy health/wealth constructs is the concept of a Health Care FICO score. I originally proposed this back in September 21, 2007 to some mild interest but mostly concern regarding its potential misuse. My efforts to define the Health Care FICO Score concept were unfortunately put forth right about the time another company was trying to develop a new model for rating health care debt differently than traditional debt (I believe that poor idea and confusing concept has appropriately died).

To rehash, I believe their needs to be a singular score, or more appropriately an index, that provides an indication of my health status. It cannot just be one measure, or provide one perspective, but a comprehensive scoring of all the important aspects of my health (health status, behaviors, satisfaction, risks, etc). An “index score” also means that it is weighted in order to normalize for race, genetics, geographies, or other factors. This sounds complicated, and I agree that it might be, but I also believe these complexities can be abstracted out into a little black box managed by statisticians, researchers, and academics as a best effort to create the health index. I don’t think people really care, or even understand, how we arrive at a financial FICO score, but they certainly care what their number is and what it means to their financial health.

The financial FICO score could, and probably should, be considered an “asset” that requires management, protection, and efforts to improve it. The FICO score is universally understood to be a surrogate measure of the level of risk one assumes in lending money to the individual. Lenders use the FICO score to determine if they want to “invest” in a relationship with the individual that is mutually beneficial. Depending on the FICO score, lenders may alter the terms up or down depending on their tolerance for risk and reward. These differential rates are the hallmark of the system and allow for natural risk selection based on behavior, choices, and past performance. It works reasonably well because we all can understand and in general agree what the FICO score means. It is not perfect, and there are problems (and occasional abuses), but in general it is effective.

I don’t see why my health asset should be any different. I think knowing my Health Care FICO score would be very valuable to me personally, would be valuable to my physician, and should be used to help create differentiation in the services I choose to invest in my health. The Health Care FICO score should be a roll up of many different measures that are indicators of my health – both traditional quality metrics as well as new vitality metrics that measures ideas such as satisfaction, nutritional status, wellness/fitness, functional status, etc. In fact, we should not just consider health the absence of disease but rather we should consider health something that we are actively pursuing. Therefore if disease subtracts from my health (or a normalized health index of 100), perhaps someone with diabetes scores an 65. However, when appropriately managed (checking glucose 3X per day, HbA1c <7.0, annual optho exam, etc), perhaps they can shoot up to an 85. However, when they become an activated patient (average sugar 120, active nutrition, exercise program), perhaps their score normalizes back to “Health Baseline” of 100.

On the other hand, a healthy individual (traditionally defined by the absence of disease), is not necessarily a ‘healthy” person. Perhaps they are the pre-diabetic, overweight, underexercised, poor nutrtion individual who is just a time bomb. The Health Care FICO score should be able to adjust for increased levels of “vitality” – active health promotion efforts wherein the individual can be rewarded for health choices and behaviors. Therefore this person can raise their Health Care FICO to 120 with getting BMI in line and cholesterol down but move to 140 as they demonstrate their vitality – active fitness programs, nutritional intake, and online community participation.

This range of scoring could be used in multiple ways, most good but clearly some bad. The key to this concept would be to come to some agreement on what metrics matter, what activities actually produce the results we want, and validate the rules/data collection so that we can actually create a reliable score. There wouldn’t need to be just one aggregated scoring system either – in the FICO world we have three companies who provide this service – and the information is used to triangulate risk assessment (each company has slightly different ways in which calculate the score).

The notion of a Vitality Index can be powerful, but it is fraught with complexity and challenge. I believe the value of having this single, agreeable index could unlock the next wave of payment, performance, and value transformation required to move our health care to a 21st century system of care.